Physical & otc/perscription permission

Shambhala Sun Summer Camp Health Form
(Please Note: A physician’s signature is required on BOTH pages 1 & 2)
Camper Name:_________________________________ Birth Date___________ Sex______ Age______ Health history: (check if appropriate)

DISORDERS
ALLERGIES
DISEASES (date)
Other_________________________________________________________________________ List any communicable diseases, surgeries, and/or serious injuries (description and date): _____________________________________________________________________________ _____________________________________________________________________________ List any known drug reactions and allergies which the camper may have: _____________________________________________________________________________ _____________________________________________________________________________ Is this child currently under a physicians care for any condition?: _____________________________________________________________________________ Any other problems or areas of concern the staff should be aware of such as activities to be avoided? _____________________________________________________________________________
*Please attach updated immunization records/ signed exemption. This child will not be permitted
to enter camp without his/her forms. To find the Colorado immunization form on line go to:
http://www.cdphe.state.co.us/dc/Immunization/Forms/CARD-Certofimm.pdf

I have examined this camper____________________(name) and found him/her to be in satisfactory
physical condition and capable of active participation in the Shambhala Sun Summer Camp activities.
Physician’s Signature:_____________________________________ Date___________________
Physician’s Address (please print or affix printed address label)
_____________________________________________________________________________
_____________________________________________________________________________
Physician’s Phone:______________________________________
Prescription and OTC Medication Permission
for Shambhala Sun Summer Camp
Over-the-Counter Medication Permission
I, the undersigned parent, give permission to the Medical Director of Sun Camp to administer the following over-the-counter medications according to existing standing orders from the licensed physician who has agreed to furnish medical services for the camp, pursuant to Section 7.711.61, A, of the Child Care Licensing code to my child, _______________________________. MEDICATION DOSAGE
AILMENT TO BE
COMMENTS
(Circle recommended) TREATED
Prescription Medication Permission
PLEASE NOTE: at Sun Camp, all medications of any kind, including prescription, asthma, over-the-counter,
dietary supplements (including vitamins), or naturopathic remedies, must be given to the camp medical
officer at the time of registration along with complete written instructions and permissions for their use. This
procedure is required by the Colorado Department of Human Services, Child Care Division.

MEDICATION DOSAGE
FREQUENCY AILMENT TO BE COMMENTS

__________ (Initials) Please do not administer any medications to my child without my direct
permission.
Parent’s Name: _______________________________ Physician’s Name_______________________________ Parent’s Signature: ____________________________ Physician’s Signature:___________________________ Date: ________________________ Date: _________________________

Source: http://shambhalasuncamp.org/wp-content/uploads/2011/11/Physical-OTC_Prescription-Permission1.pdf